Senior living community penalized after resident with dementia elopes, dies

A North Carolina senior living community has been told not to accept new residents after a resident with dementia wandered away from the community and later was found dead.

The state Department of Health and Human Services' Division of Health Service Regulation told Brookdale Elizabeth City, Elizabeth City, NC, in a March 23 letter that admissions were suspended, based on a Feb. 28 statement of deficiencies, “until conditions or circumstances merit removing the suspension.”

The division also intends to downgrade the community's license to provisional status, Megan Lamphere, MSW, chief of the adult care licensure section, said in a separate letter dated the same day, unless Brookdale can demonstrate compliance within 10 days.

The actions follow the death of 90-year-old resident Ruby Whedbee, 90, who walked away from the community Feb. 20 and was found dead the next day in a greenhouse about half a mile away, according to the department. Temperatures while she was gone from the community ranged from approximately 40 to 57 degrees, according to the department.

The Feb. 28 statement of deficiencies, based on an annual and follow-up survey and complaint investigation conducted Feb. 22 to 24, found that four sampled residents, all of whom either had a dementia diagnosis or were characterized as intermittently or constantly disoriented, were able to exit the building without the staff's knowledge because the community did not have an alarm that activated when the front door was opened. One of the residents with a dementia diagnosis and documented confusion was Whedbee, according to the statement, which did not refer to her by name.

Brookdale's district director of clinical services told surveyors that the community had a wander management system with an alarm on the front door, but the system had been deactivated and residents did not wear signaling devices that would have set off the alarm had the system been working, according to the report.

Whedbee, who lived in the assisted living part of the building, not the memory care unit, had eloped before, according to the report. She had not been assessed for a signaling device, the administrator told investigators.

A spokeswoman for Brookdale Senior Living told McKnight's Senior Living: “We are aware that the North Carolina Department of Human Services has restricted our ability to allow new residents to move into our community. Our community is cooperating and communicating with state regulators to timely address this matter. The health and safety of our residents is our top priority, and we are committed to enriching the lives of those we serve with compassion, respect, excellence and integrity.”

The deficiency statement noted that the community administrator provided a plan of protection for all residents that includes alarming and locking the front door every day from 6 p.m. to 9 a.m.; stationing a staff member at the front desk at all times between 9 a.m. and 6 p.m.; and placing transmitter bands on the ankles of all residents identified as having dementia or intermittent disorientation, to lock the front door, sound alarms and alert staff if they try to exit. Additionally, signaling devices have been ordered for all residents who have a diagnosis of dementia with intermittent disorientation, and staff will contact the administrator, health and wellness director, medical director and family if a resident's confusion increases, so the resident can be evaluated by a physician to see whether a transfer to a special care unit would be appropriate.

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